While I believe the intent is noble, I have concerns about fortification as the solution to nutritional deficiency, at least beyond the very short term. After a quick search, I came to learn my concerns were shared by the scientific community in India, and have been widely reported on by the Indian mainstream media.
The first news item references an article published in The Lancet suggesting that widespread iron deficiency among children and adolescents in India was largely an artifact of arbitrarily high cut-offs set by the WHO.
Using cut-offs based on age and gender-adjusted 5th percentile of the healthy population in India based on its national nutrition survey (CNNS), the incidence of anemia declines by two thirds, from 30.0 to 10.8 percent. It is worth noting that the cut-off based on the CNNS was not dramatically lower than that used by the WHO (see Figure 3 in the referenced article), suggesting many children have barely adequate iron status and could be at risk of deficiency.
This sentence in the news story was of particular interest: “Is there an Indian diet that can meet these requirements? Indeed, there is. You don’t need to fortify to meet the requirements of 15-18 mg of iron per day in the Indian diet,” Dr. Kurpad explained in a webinar.
The interest stems from the relatively high dietary requirements set in India. For context, the US recommended daily allowance (RDA) for children between the ages of 1 and 18 range from 7 to 15 mg of iron per day based on age and gender.
In terms of whether an easily accessible Indian diet could meet those requirements, one cup of spinach, one cup of lentils and two whole-wheat (ie non-fortified) pieces of naan bread provide 17mg of iron in only 870 calories, barely 40% of the caloric intake considered adequate by the WHO for a moderately healthy adult. These are widely available, commonly consumed and inexpensive staples of the Indian diet.
The news story also makes another important point that advocates of fortification fail to consider. With a minority of the population suffering from deficiency, targeted supplementation makes more sense: “Just putting more and more into the diet places a part of the population at risk of exceeding the tolerable upper limit of intake at which adverse events begin to occur,” says Dr. Kurpad.
The second news story adds a few more salient points. It references two other scientific artlcles, from the American Journal of Clinical Nutrition that conclude fortification could cause gut disbiosis and lead to hypervitaminosis.
A letter cosigned by 170 scientists, including the former deputy director of the National Institute of Nutrition, notes that many of the studies upon which the Indian government was relying to promote fortification were sponsored by food companies who would benefit from it, leading to conflicts of interest. Studies funded by the Nestle Nutrition Institute and the Global Alliance for Improved Nutrition were specifically mentioned.
A link to the full letter, the names of its signatories and numerous academic citations can be found here:
Just throwing out the word ‘evidence-based’ without citing the evidence is problematic. As the letter from the Indian scientists contesting the government’s push for mandatory fortification suggests, there appears to be a great deal of evidence suggesting detrimental short and long-term impacts of food fortification as a means of addressing nutritional deficiency.
Also, while I am new to Effective Altruism, I imagine any such concept at the minimum should take into account the needs, wants and long-term well-being of the targeted population, which appears not to have been taken into consideration with respect to food fortification in India.
While I believe the intent is noble, I have concerns about fortification as the solution to nutritional deficiency, at least beyond the very short term. After a quick search, I came to learn my concerns were shared by the scientific community in India, and have been widely reported on by the Indian mainstream media.
New study calls for restraint in ‘unnecessary’ food fortification
Jagriti Chandra, The Hindu
JULY 30, 2021
https://www.thehindu.com/sci-tech/health/new-study-calls-for-restraint-in-unnecessary-food-fortification/article35640607.ece
Experts raise concerns over mandatory fortification of food items
Special Correspondent, The Hindu
AUGUST 02, 2021
https://www.thehindu.com/news/national/experts-raise-concerns-over-mandatory-fortification-of-food-items/article35685066.ece
The first news item references an article published in The Lancet suggesting that widespread iron deficiency among children and adolescents in India was largely an artifact of arbitrarily high cut-offs set by the WHO.
Haemoglobin thresholds to define anaemia in a national sample of healthy children and adolescents aged 1–19 years in India: a population-based study
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(21)00077-2/fulltext
Using cut-offs based on age and gender-adjusted 5th percentile of the healthy population in India based on its national nutrition survey (CNNS), the incidence of anemia declines by two thirds, from 30.0 to 10.8 percent. It is worth noting that the cut-off based on the CNNS was not dramatically lower than that used by the WHO (see Figure 3 in the referenced article), suggesting many children have barely adequate iron status and could be at risk of deficiency.
This sentence in the news story was of particular interest: “Is there an Indian diet that can meet these requirements? Indeed, there is. You don’t need to fortify to meet the requirements of 15-18 mg of iron per day in the Indian diet,” Dr. Kurpad explained in a webinar.
The interest stems from the relatively high dietary requirements set in India. For context, the US recommended daily allowance (RDA) for children between the ages of 1 and 18 range from 7 to 15 mg of iron per day based on age and gender.
In terms of whether an easily accessible Indian diet could meet those requirements, one cup of spinach, one cup of lentils and two whole-wheat (ie non-fortified) pieces of naan bread provide 17mg of iron in only 870 calories, barely 40% of the caloric intake considered adequate by the WHO for a moderately healthy adult. These are widely available, commonly consumed and inexpensive staples of the Indian diet.
The news story also makes another important point that advocates of fortification fail to consider. With a minority of the population suffering from deficiency, targeted supplementation makes more sense: “Just putting more and more into the diet places a part of the population at risk of exceeding the tolerable upper limit of intake at which adverse events begin to occur,” says Dr. Kurpad.
The second news story adds a few more salient points. It references two other scientific artlcles, from the American Journal of Clinical Nutrition that conclude fortification could cause gut disbiosis and lead to hypervitaminosis.
The effects of iron fortification on the gut microbiota in African children: a randomized controlled trial in Côte d’Ivoire
https://academic.oup.com/ajcn/article/92/6/1406/4597520
Vitamin A deficiency among children younger than 5 y in India: an analysis of national data sets to reflect on the need for vitamin A supplementation
https://academic.oup.com/ajcn/article/113/4/939/6039538
A letter cosigned by 170 scientists, including the former deputy director of the National Institute of Nutrition, notes that many of the studies upon which the Indian government was relying to promote fortification were sponsored by food companies who would benefit from it, leading to conflicts of interest. Studies funded by the Nestle Nutrition Institute and the Global Alliance for Improved Nutrition were specifically mentioned.
A link to the full letter, the names of its signatories and numerous academic citations can be found here:
https://im4change.org/upload/files/ASHAs%20letter%20to%20FFRC%20on%20mandatory%20fortification%20Aug%202021.pdf
Just throwing out the word ‘evidence-based’ without citing the evidence is problematic. As the letter from the Indian scientists contesting the government’s push for mandatory fortification suggests, there appears to be a great deal of evidence suggesting detrimental short and long-term impacts of food fortification as a means of addressing nutritional deficiency.
Also, while I am new to Effective Altruism, I imagine any such concept at the minimum should take into account the needs, wants and long-term well-being of the targeted population, which appears not to have been taken into consideration with respect to food fortification in India.